HACKLEY COMMUNITY CARE CENTER (HCCC)HACKLEY COMMUNITY CARE CENTER (HCCC)

CEDRIC H. SCOTT, LLP,CAC-R CEDRIC H. SCOTT, LLP,CAC-R

Behavioral Health Behavioral Health Integration into Integration into Primary CarePrimary Care

HCCC’s DemographicsHCCC’s Demographics Located in Muskegon Heights, MILocated in Muskegon Heights, MI We have 140 employeesWe have 140 employees 6 Physicians6 Physicians 7 Physician Assistants7 Physician Assistants 3 Nurse Mid-wives3 Nurse Mid-wives 2 LLP2 LLP 1 MSW1 MSW 2 BSW2 BSW DentalDental

HCCC’s Demographics Con’tHCCC’s Demographics Con’t Over 15,000 clientsOver 15,000 clients 20% uninsured20% uninsured 60% medicaid60% medicaid 10% medicare10% medicare 9% private9% private More than 841 depression disorder More than 841 depression disorder

patientspatients

Five Levels of IntegrationFive Levels of Integration Level 1 -Minimal CollaborationLevel 1 -Minimal Collaboration Level 2 - Basic Collaboration at a Level 2 - Basic Collaboration at a

DistanceDistance Level 3 - Basic Collaboration On-Level 3 - Basic Collaboration On-

SiteSite Level 4 - Close Collaboration in a Level 4 - Close Collaboration in a

Partly Integrated SystemPartly Integrated System Level 5 - Close Collaboration in a Level 5 - Close Collaboration in a

Fully Integrated SystemFully Integrated System

Level 1- Minimal CollaborationLevel 1- Minimal Collaboration Description:Description: Mental Health and Mental Health and

other health care professionals work other health care professionals work in separate facilities, have separate in separate facilities, have separate systems, and rarely communicate systems, and rarely communicate about cases.about cases.

Where practiced:Where practiced: Most private Most private practices and agencies.practices and agencies.

Level 1 Con‘t Level 1 Con‘t Handles adequately: Handles adequately: Cases with Cases with

routine medical or psychosocial routine medical or psychosocial problems that have little problems that have little biopsychosocial interplay and few biopsychosocial interplay and few management difficulties.management difficulties.

Handles inadequately: Handles inadequately: Cases that Cases that are refractory to treatment or have are refractory to treatment or have significant biopsychosocial interplay.significant biopsychosocial interplay.

Level 2 – Basic Collaboration at Level 2 – Basic Collaboration at a Distancea Distance

Description:Description: Providers have separate Providers have separate systems at separate sites, but engage systems at separate sites, but engage in periodic communication about shared in periodic communication about shared patients, mostly through telephone and patients, mostly through telephone and letters. All communication is driven by letters. All communication is driven by specific patient issues. specific patient issues.

Where practiced: Where practiced: Settings where Settings where there are active referral linkages across there are active referral linkages across facilities.facilities.

Level 2 Con’tLevel 2 Con’t Handles adequately: Handles adequately: Cases with Cases with

moderated biopsychosocial interplay, for moderated biopsychosocial interplay, for example, a patient with diabetes and example, a patient with diabetes and depression where the management of depression where the management of both problems proceeds reasonably well.both problems proceeds reasonably well.

Handles inadequately: Handles inadequately: Cases with Cases with significant biopsychosocial interplay, significant biopsychosocial interplay, especially when the medical or mental especially when the medical or mental health management is not satisfactory to health management is not satisfactory to one of the parties.one of the parties.

Level 3 – Basic Collaboration Level 3 – Basic Collaboration On-SiteOn-Site

Description: Description: Mental health and Mental health and other health care professionals have other health care professionals have separate systems but share the same separate systems but share the same facility. As in Levels one and two, facility. As in Levels one and two, medical physicians have considerably medical physicians have considerably more power and influence over case more power and influence over case management decisions than the management decisions than the other professionals, who may resent other professionals, who may resent this.this.

Level 3 Con’tLevel 3 Con’t Where practiced: Where practiced: HMO settings HMO settings

and rehabilitation centers where and rehabilitation centers where collaboration is facilitated by collaboration is facilitated by proximity, but where there is no proximity, but where there is no systemic approach to collaboration systemic approach to collaboration and where misunderstandings are and where misunderstandings are common. common.

Level 3 Con’tLevel 3 Con’t Handles adequately: Handles adequately: Cases with Cases with

moderate biopsychosocial interplay moderate biopsychosocial interplay that require occasional face-to-face that require occasional face-to-face interactions between providers to interactions between providers to coordinate complex treatment plans.coordinate complex treatment plans.

Handles inadequately:Handles inadequately: Cases with Cases with significant biopsychosocial interplay, significant biopsychosocial interplay, especially those with ongoing and especially those with ongoing and challenging management problems.challenging management problems.

Level 4 – Close Collaboration in a Level 4 – Close Collaboration in a Partly Integrated SystemPartly Integrated System

Description: Description: Mental health and other Mental health and other health care professionals share the health care professionals share the same sites and have some systems in same sites and have some systems in common, such as scheduling or charting. common, such as scheduling or charting.

Where practiced:Where practiced: Some HMOs, Some HMOs, rehabilitation centers, and hospice rehabilitation centers, and hospice centers that have worked systematically centers that have worked systematically at team building. Also some family at team building. Also some family practice training programs.practice training programs.

Level 4 Con’tLevel 4 Con’t Handles adequately: Handles adequately: Cases with Cases with

significant biopsychosocial interplay and significant biopsychosocial interplay and management complications.management complications.

Handles inadequately: Handles inadequately: Complex Complex cases with multiple providers and cases with multiple providers and multiple larger systems involvement, multiple larger systems involvement, especially when there is the potential for especially when there is the potential for tension and conflicting agendas among tension and conflicting agendas among providers or triangling on the part of the providers or triangling on the part of the patient or family.patient or family.

Level 5 – Close Collaboration in a Level 5 – Close Collaboration in a Fully Integrated SystemFully Integrated System

Description: Description: Mental health and Mental health and other health care professionals share other health care professionals share the same sites, the same vision, and the same sites, the same vision, and the same systems in a seamless web the same systems in a seamless web of biopsychosocial services. of biopsychosocial services.

Where practiced: Where practiced: Some hospice Some hospice centers and other special training centers and other special training and clinical settings.and clinical settings.

Level 5 Con’t Level 5 Con’t Handles adequately: Handles adequately: The most The most

difficult and complex biopsychosocial difficult and complex biopsychosocial cases with challenging management cases with challenging management problems.problems.

Handles inadequately: Handles inadequately: Cases Cases where the resources of the health where the resources of the health care team are insufficient or where care team are insufficient or where breakdowns occur in the collaboration breakdowns occur in the collaboration with larger service systems.with larger service systems.

Hackley Community Care Center Hackley Community Care Center Integrated BHIntegrated BH

Providers refer patientsProviders refer patients Realtime visitsRealtime visits Consulting with providersConsulting with providers Shared decision making/txShared decision making/tx Mental health reimbursement barriersMental health reimbursement barriers Outside referralsOutside referrals BarriersBarriers

• ReimbursementReimbursement• ParityParity

HCCC’s ProgramsHCCC’s Programs School-based health programsSchool-based health programs Substance abuse treatmentSubstance abuse treatment Pain managementPain management Behavioral health care screening Behavioral health care screening

toolstools

ReferencesReferences Five Levels of Primary care/behavorial Five Levels of Primary care/behavorial

Healthcare CollaborationHealthcare Collaboration• William J. Doherty, University of MinnesotaWilliam J. Doherty, University of Minnesota• Susan H. McDaniel, Ph.D., University of Susan H. McDaniel, Ph.D., University of

RochesterRochester• Macaran A. Baird, M.D., HealthPartners, Macaran A. Baird, M.D., HealthPartners,

Minneapolis, MNMinneapolis, MN

Behavioral Healthcare TomorrowBehavioral Healthcare Tomorrow, October, , October, 1996, 25-28.1996, 25-28.

References Con’tReferences Con’t

Integration of Mental Health/Substance Integration of Mental Health/Substance Abuse and Primary CareAbuse and Primary Care

Minnesota Evidence-based Practice Minnesota Evidence-based Practice Center, Minneapolis, MinnesotaCenter, Minneapolis, Minnesota

Muskegon Family Muskegon Family CareCare

Behavioral Health ServicesBehavioral Health Services

Gwen Williams, LMSWGwen Williams, LMSW

williamg@mfc-health.orgwilliamg@mfc-health.org

Why BH in Primary Care?Why BH in Primary Care? Depression - 25% of primary care visitsDepression - 25% of primary care visits 50% of depressed patients receive all care for 50% of depressed patients receive all care for

depression in primary caredepression in primary care Detection and correct diagnosis often not Detection and correct diagnosis often not

identifiedidentified Antidepressants used at lower intensityAntidepressants used at lower intensity 1/3 of patients stop antidepressant in first 30 1/3 of patients stop antidepressant in first 30

days days Only 50% of patients referred to specialty MH Only 50% of patients referred to specialty MH

complete more than one visit complete more than one visit

History of BH at MFCHistory of BH at MFC MFC started as a small DO Family MFC started as a small DO Family

Practice Residency clinic then got Practice Residency clinic then got CHC look-alike in 1996.CHC look-alike in 1996.

MSW hired as Behavioral Science MSW hired as Behavioral Science Educator and began providing Educator and began providing counseling services as well as counseling services as well as teaching residents and evaluating teaching residents and evaluating their skills in communication and their skills in communication and relationship development. relationship development.

History of BH at MFC, cont.History of BH at MFC, cont. Began billing for services in 1998Began billing for services in 1998 Completed a pro forma to expand Completed a pro forma to expand

services, and contracted with outside services, and contracted with outside mental health agency to provide mental health agency to provide part-time therapists at 2 sites, with part-time therapists at 2 sites, with model of half hour billed visits.model of half hour billed visits.

Joined Depression Collaborative and Joined Depression Collaborative and began using MSW Interns as well as a began using MSW Interns as well as a clinic counselor for depression care clinic counselor for depression care management. management.

Current StaffingCurrent Staffing 2 full-time MSW Therapists (1 at each site) 2 full-time MSW Therapists (1 at each site)

providing half-hour billable visits, fully providing half-hour billable visits, fully scheduledscheduled

2 part-time MSW Therapists (paid on per-2 part-time MSW Therapists (paid on per-visit model) providing billable visitsvisit model) providing billable visits

2 full-time master’s level Clinic Counselors 2 full-time master’s level Clinic Counselors who provide care management for who provide care management for depression and ADHD follow-up depression and ADHD follow-up

3 Social Work Interns (2 BSW, 1 MSW) who 3 Social Work Interns (2 BSW, 1 MSW) who provide ADHD assistance, depression care provide ADHD assistance, depression care management and resource referrals management and resource referrals

Services ProvidedServices Provided

1,373 mental health encounters 1,373 mental health encounters 2003 up to 4,280 mental health 2003 up to 4,280 mental health encounters 2008encounters 2008

11,500 significant phone, mail 11,500 significant phone, mail and face-to-face encounters and face-to-face encounters provided by Clinic Counselors in provided by Clinic Counselors in last yearlast year

Existing Challenges / GapsExisting Challenges / Gaps

Substance Abuse Services (SBIRT Substance Abuse Services (SBIRT pilot)pilot)

Real-time consult, making full Real-time consult, making full use of H-Code billinguse of H-Code billing

Psychiatric consult / servicesPsychiatric consult / services Communication / coordination Communication / coordination

with CMH with CMH

Community Mental Community Mental Health Services of Health Services of Muskegon CountyMuskegon County

Integrated Health Care Integrated Health Care InitiativeInitiative

The ProblemThe Problem

““Our minds and our bodies are Our minds and our bodies are always together in our lives, always together in our lives, except when we enter the health except when we enter the health care system. There they are care system. There they are often separated, and totally often separated, and totally distinct specialties take over.”distinct specialties take over.”

Cynthia M. Watson, M.D.

thepfizerjournal.com

Why Should We Be Concerned?Why Should We Be Concerned?

Individuals with serious mental Individuals with serious mental illness served by our public mental illness served by our public mental health systems die, on average, 25 health systems die, on average, 25 years earlier than the general years earlier than the general population. population.

NASMHPD 2006

Maine Study Results: Comparison of Maine Study Results: Comparison of Health Disorders Between SMI & Non-SMI Health Disorders Between SMI & Non-SMI

GroupsGroups

59.4

33.930 28.6 28.4

22.8 21.716.5

11.5 11.16.3 5.9

0

10

20

30

40

50

60

70

80

Skeletal- Connective

Gastro-Intestinal

Obesity/Dyslipid

COPDInfectious Disease

Hypertension

Dental Disorders

Diabetes

Cancer

Heart Disease

Pneumonia/Influenza

Liver Disease

Pe

rce

nt

Me

mb

ers

SMI (N=9224)

Non-SMI (N=7352)

Four Quadrant Integration ModelFour Quadrant Integration Model

Low High

Quadrant I

BH low, PH low

Quadrant III

BH low, PH high

Quadrant II

BH high, PH low

Quadrant IV

BH high, PH high

Physical Health Risk/ Status

Low

High

CMH or PCP Medical Home

PCP Medical Home

PCP Medical Home

CMH and PCP Co-managed Care

Benefits of Medical Home ModelBenefits of Medical Home Model

Improved access to careImproved access to care Stigma reductionStigma reduction Less resistance to referralsLess resistance to referrals Better communicationBetter communication Adaptations made to factor in the impact Adaptations made to factor in the impact

of mental illness on disease managementof mental illness on disease management Primary care provider educationPrimary care provider education Insights into clinical, structural, funding Insights into clinical, structural, funding

modelsmodels May improve medical outcomes and lead May improve medical outcomes and lead

to medical cost offsetto medical cost offset

AccomplishmentsAccomplishments

Providing one time Psychiatric Providing one time Psychiatric ConsultationConsultation

Establishing a Medical Home Establishing a Medical Home Increased collaboration with the Increased collaboration with the

Federally Qualified Health CentersFederally Qualified Health Centers Providing CMH staff with training Providing CMH staff with training

regarding medical conditionsregarding medical conditions Beginning the planning process to Beginning the planning process to

co-locate staffco-locate staff

AccomplishmentsAccomplishments

Received a planning grant to assist with Received a planning grant to assist with coordination / integrationcoordination / integration

Memorandum of Understanding with the Memorandum of Understanding with the Federally Qualified Health ClinicsFederally Qualified Health Clinics

““All parties recognize that multiple barriers All parties recognize that multiple barriers currently exist in the health care systems currently exist in the health care systems that prevent individuals from accessing that prevent individuals from accessing care and continuing the type of care they care and continuing the type of care they require to improve their health and require to improve their health and functioning”.functioning”.

AccomplishmentsAccomplishments

Collaboration with a local Pediatric Collaboration with a local Pediatric Practice to assure there is a Practice to assure there is a coordinated effort in providing care coordinated effort in providing care for children receiving servicesfor children receiving services

Increasing the presence of CMH staff Increasing the presence of CMH staff in the emergency rooms, hospitals, in the emergency rooms, hospitals, and doctor’s office to advocate for and doctor’s office to advocate for improved coordination of health careimproved coordination of health care

National Wellness SummitNational Wellness SummitWellness PledgeWellness Pledge

We Envision:We Envision:    a future in which people with mental a future in which people with mental illnesses pursue optimal health, happiness, illnesses pursue optimal health, happiness, recovery, and a full and satisfying life in the recovery, and a full and satisfying life in the community via access to a range of effective community via access to a range of effective services, supports, and resources.services, supports, and resources.   

We pledge:We pledge:    to promote wellness for people with mental to promote wellness for people with mental illnesses by taking action to prevent and illnesses by taking action to prevent and reduce early mortality by 10 years over the reduce early mortality by 10 years over the next 10 year time period.next 10 year time period.